Like Pulling Teeth: Finding Accessible Dental Care

On the list of life’s unpleasant chores, going to the dentist has to rank pretty close to the top. The smell of the dentist’s office, the sting of the injection, the whine of the drill, the sharp metal instruments and latex-clad fingers poking around in your mouth — dozens of horror movies and stand-up comedy routines have been based on the whole experience. Still, we put up with it — or at least, know that we should — because an afternoon of suffering once or twice a year is worth it if it means keeping all your teeth.

But what if your wheelchair won’t fit through the door? What if you’re unable to transfer into the dentist’s chair? What if your dentist knows nothing about your disability and how it might affect your teeth? Or what if you’re uninsured, or on Medicaid and you can’t even find a dentist that will take you?

In recent years, much attention has been paid to the barriers — physical, attitudinal and financial — people with disabilities face getting the medical care they need. Less noticed, however, are similar problems accessing dental care. While it may be tempting to avoid those problems by putting off that routine teeth-cleaning, that can lead to more serious problems down the line. As any doctor will tell you, the health of your teeth can have a huge impact on the health of the rest of your body.

The end result of neglecting it all can be … well, about as much fun as a toothache.

Pay Now or Pay Later
Mike Collins, 66, is diligent about his own dental health. He once went several years without going to the dentist but then, he says, “paid for it with a couple of cavities.” Since then, the C5 quad from Redmond, Wash., has made a point of having routine checkups every six months. Most of the time, mobility isn’t an issue. Although unable to transfer on his own, Collins uses a reclining power chair, and his dentists have always been willing to work on him there.

In January, however, Collins had to go to an oral surgeon to have a tooth extracted. This dentist, whom he had never seen before, insisted that he had to transfer to the office’s dental chair. “I had to take my attendant along to help transfer me — I actually took my daughter as well,” Collins says. “It cost me extra money to pay the attendant.”

Mark Plocharczyk, 46, who has spinal muscular atrophy, also needs to stay in his wheelchair during dental procedures. Until very recently, he was able to use a dentist — “my wife’s family’s dentist” — who was both close to his Crestwood, Ill., home and accommodating to his disability. Then his wife’s insurance coverage changed, and he had to find a new one. “I had to call 10 different offices to find one that took our insurance and also would allow me to stay in my chair,” Plocharczyk says. “It took us three or four months.”

As a T10 para with a lot of upper-body strength, New Mobility contributor Bob Vogel has no trouble transferring out of his own wheelchair. His challenge is financial: As a recipient of Medi-Cal (the state of California’s version of Medicaid), Vogel has been stymied in finding a dentist who will accept his coverage. “I buckle down and pay in cash,” he says, “about 75 bucks per visit for a cleaning.” He chooses to pay out of pocket, though, because the cost of not doing so would be even higher. “I’m a fanatic about my teeth, because I can’t afford not to be. Having regular dental checkups has enabled me to avoid massive dental bills.”

Removing Barriers
According to Dr. Bart Johnson of Seattle Special Care Dentistry — a dental group with the mission of providing care to people with physical and mental disabilities — people like Vogel are wise to be proactive.

“Any time you allow a health decline to occur, you’re going to feel the ramifications of it,” Johnson says. “In the oral cavity, that means tooth loss, pain, chronic infection. And it’s been well proven that bacteria in the mouth can feed into the bloodstream and difficulties in other areas of the body.”

When one’s body is already compromised by physical disability, those difficulties can be even more severe. For a person with SCI, for example, an immune system taxed by an abscessed tooth or gum disease can weaken the body’s ability to fight off UTIs or heal pressure sores. Also, many medications that control pain or spasticity cause dry mouth — a side effect that can have a detrimental effect on the health of the teeth.
Often, Johnson says, people who forego routine dental care “end up with acute infections and then struggle to find care on an emergency basis when it’s much more difficult and costly.”

With that in mind, Johnson and partners set out to build a practice without barriers that prevent people with disabilities from seeking dental care. “We started with an empty shell and designed in all the things we knew are helpful to a dental practice dedicated to wheelchair users,” he says. Besides widened doors and extra-large exam rooms for power chairs, they also have a Hoyer lift for transferring into the dental chair — though they will also let the person stay in the wheelchair if desired.

[Another lift manufacturer, SureHands, says it has worked with dentist offices to install lifts for transferring wheelchair users into dental chairs.]
Their patients notice the accommodations, and appreciate them, Johnson says. “Many of them have told us how nice it is just to be able to get into the office.”

Searching for Solutions
Getting in the door is one thing — paying for the work is another. With so many people with disabilities dependent on Medicare and Medicaid for their health-care needs, the lack of dental coverage is yet another barrier.
Medicare doesn’t cover routine dental checkups. And Medicaid? The Medicaid coverage that does exist typically comes at such a low rate of reimbursement that it dissuades many dentists from taking on Medicaid recipients. “Here in Washington state, [reimbursement is] 23 cents on the dollar,” Johnson says. “When your overhead is 50 cents, you literally lose money every time you see a Medicaid patient.”

Dr. Jason Grinter, board member of the Chicago-based Special Care Dentistry Association, agrees: “It’s a problem for individuals who rely on federal and state funding — there are very few providers that accept Medicaid. Really, there are not a lot of places for them to go.”

The SCDA’s website — www.scdaonline.org — includes a database of members that is searchable by state, zip code and type of insurance accepted, enabling some people with disabilities to locate an accessible dentist in their area. Both Grinter and Johnson also recommend local dental associations as a resource. “In my opinion, the best thing to do is just ask around,” Johnson says. “The dentists in the local community typically know best what’s out there.” At the same time, he cautions people with complex medical issues that they may have to look outside their immediate vicinity to find a dentist who meets their needs. “The sort of access that they’re looking for might be 300 miles away — you have to be kind of ready for that.”

With resources so limited, for many people with disabilities, obtaining appropriate dental care remains a matter of old-fashioned networking. “The only advice I can give is to keep plugging away,” Plocharczyk says. “Ask friends and family if they have a good dentist that they like — those may be a little more willing to work with you. Whether a dentist office lists anything about accessibility or whether they work with disabled people, they have to be good dentists to begin with.”

Vogel also suggests consulting with local disability-related resources, such as centers for independent living and SCI support groups. And once you have found a dentist, it is critical to know whether he or she is aware of the issues surrounding your disability — or is willing to learn. “With all my dentists, I’ve spent the time to educate them,” says Vogel. “It’s just like with a regular doctor — you have to ask proactive questions. ‘Do you understand my situation?’ ‘Have you worked with people with spinal cord injuries before?’ Making sure they know how to keep me alive. It’s the same thing with a dentist.

“I don’t like having my teeth cleaned,” Vogel says. “But I like it a lot better than having a root canal.”